Provider Demographics
NPI:1396341186
Name:ESTRADA, MATTHEW ROBERT (LPC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROBERT
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 N BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2907
Practice Address - Country:US
Practice Address - Phone:970-765-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO182781101YS0200X
CO0011181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool